Delivering a Healthy WA
Disease WAtch

June 2013, Volume 17, Issue 2

Full issue

New combined measles mumps rubella varicella vaccine introduced

A combination vaccine for measles, mumps, rubella and varicella (MMRV) for children 18 months of age will be added to the National Immunisation Program (NIP) schedule from 1 July 2013.

What's changing?

As a result of its introduction, the second dose of the measles, mumps, rubella (MMR) vaccine, previously given at four years of age, will be brought forward to 18 months of age and will be delivered with the varicella vaccine (already scheduled at 18 months) as the combination MMRV vaccine. This move will provide earlier two-dose protection for children against measles, mumps and rubella, and is likely to result in an increased uptake of the second dose of MMR.

Children who have already received their 18 month varicella vaccination should still be immunised for measles, mumps and rubella (MMR) at four years of age. The four year MMR schedule point will remain until all children aged between 18 months and four years of age, as at 1 July 2013, reach the age of four years—that is, 31 December 2015.

Who is eligible to receive free MMRV vaccine?

A child presenting after 1 July 2013 who has received his or her 12 month MMR vaccination, but not the18 month varicella vaccine, should be vaccinated with MMRV at 18 months. Children aged between 18 months and 4 years who have missed the scheduled 18 month old varicella vaccine should receive MMRV as soon as possible.

Prior varicella infection is not a contraindication to vaccination; children who have been infected with chickenpox can still receive the MMRV vaccine. There is no known increase in adverse events from vaccinating those with pre-existing immunity to one or more of the vaccine components. Monovalent varicella vaccine will only be routinely available to the school immunisation program where a catch up program is delivered to children aged 10–13 years.

MMRV must be given as a second dose schedule vaccine following vaccination with MMR vaccine offered to children at 12 months of age. This is due to a small but increased risk of fever and febrile seizures when this combined vaccine was given as a first MMR-containing vaccine dose in one year olds.

A child aged between 18 months and 14 years who has never had the MMR vaccine (or whose vaccination status is unclear or unknown) should be administered MMR as a first dose. The MMRV vaccine can then be administered four weeks later as the second dose of MMR-containing vaccine. If MMR has previously been given, MMRV can be administered as the second dose.

If MMRV vaccine is inadvertently administered at 12 months of age as a first MMR dose, the dose does not need to be repeated. However, parents/carers should be advised of the small but increased risk of fever and febrile seizures compared with that expected following MMR vaccine.

Background

Measles immunity induced by one dose vaccination provides long-term immunity in most recipients. However, approximately 5% of recipients fail to develop immunity to the first dose of measles vaccine but achieve 99% immunity following a second dose of vaccine.

The combination MMRV vaccine has been shown in clinical trials (conducted in children 12 months to 6 years) to produce simular rates of seroconversion to all four vaccine components compared with MMR and monovalent varicella vaccines administered concomitantly at separate injection sites.

Further information

The Commonwealth Government plans to write to parents of children approaching 18 months of age in June 2013 to alert them to this change in schedule and advise them to make appointments with their immunisation service providers to obtain the new MMRV vaccine. This mail-out will occur monthly until June 2014.

Other campaign resource material, such as posters, an updated schedule for providers, media releases and website information has also been developed to raise awareness of the new vaccine’s availability. For further information see the Australian Immunisation Handbook 10th Edition 2013.

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New State immunisation plan launched

On 21 May 2013, the Minister for Heath, Dr Kim Hames, launched the Western Australian Immunisation Strategy 2013–2015. The new strategy has had extensive input from immunisation partners throughout the State and provides clinicians, administrators, and policy makers with clear direction on WA Health’s priorities for delivering quality immunisation services.

The WA Immunisation Strategy 2013–2015 seeks to:

  • provide strategies to meet immunisation coverage benchmarks contained in the National Partnership Agreement for Essential Vaccines
  • improve immunisation rates among Aboriginal and Torres Strait Islander populations and children in geographic areas with low vaccination rates
  • improve immunisation consent processes in WA
  • ensure sustained implementation of the recommendations from the 2010 Stokes Review (PDF 2.52MB) into adverse events following immunisation
  • enhance surveillance for vaccine-preventable diseases in WA.

Implementation of the WA Immunisation Strategy 2013–2015 will be overseen by the Western Australia Immunisation Strategic Advisory Group. The Strategy should serve as a framework for establishing programs and partnerships that strengthen our capacity to protect the health of our communities through immunisation. The WA Immunisation Strategy 2013–2015 can be viewed on the public health website (PDF 3.14MB)

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New definition for fully vaccinated child

In November 2011 the Australian Government announced the Strengthening Immunisation for Children (external site) initiative. This initiative included:

  • ending the Maternity Immunisation Allowance (MIA) from 1 July 2012
  • introducing an immunisation assessment for Family Tax Benefit part A Supplement (12 mth, 24 mth, and 60 mth assessments ) from 1 July 2012
  • introducing the combined measles, mumps, rubella, varicella (MMR-V) vaccine at 18 months of age from 1 July 2013
  • the addition of pneumococcal, meningococcal C and varicella vaccines to the definition of being fully immunised from 1 July 2013.

Immunisation service providers should already have received information relating to the introduction of an immunisation assessment for Family Tax Benefit part A Supplement (12 mth, 24 mth, and 60 mth assessments) from 1 July 2012. This information is available at the Parliament of Australia website (external site)

The new definition of fully immunised (for the purpose of family payments) will affect the coverage rates as the affected birth cohort of children born after 1 July 2012 flows through the different age assessment points.

Childhood immunisation coverage rates in WA are currently around 89% to 90%. However, effective disease control requires 95% coverage.

While inclusion of the additional vaccines will be beneficial to assessing the overall immune protection achieved in the 0–5 year age cohort in the long term, immunisation rates in WA will initially decline owing to parents not getting their children vaccinated at the recommended times e.g. 1 year and 18 months for vaccines such as meningococcal C and varicella.

To prevent this decline in our immunisation rates, immunisation service providers are encouraged to actively promote the uptake of all vaccines on the WA schedule at the recommended time. This should ensure our rates do not fall below 90% and that our children and the broader community are protected.

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Australia commits to new HIV/AIDS targets

Australia has committed to new HIV prevention and treatment targets by becoming a signatory to the 2011 United Nations’ Political Declaration on HIV/AIDS. The targets include:

  • reducing the sexual transmission of HIV by 50 per cent by 2015
  • redoubling HIV prevention efforts by—among other things—expanding and promoting voluntary and confidential HIV testing and counselling, and provider-initiated HIV testing and counselling.

To meet these new targets, Australia will need to increase HIV testing of people at risk of HIV to reduce the pool of people with undiagnosed HIV infection and achieve earlier diagnosis.

The HIV Model of Care Implementation Plan 2010–2014, in line with the Sixth National HIV Strategy 2010–2013, identifies a number of target groups including people from (or who travel to) high-prevalence countries. This will include any men who have the capacity to travel frequently either for work or pleasure.

In 2012, there were 122 new HIV notifications in WA, 16% more than in the previous 12 months. Male heterosexual notifications rose from 26 in 2011 to 35 in 2012, a 35% increase. Most of these men acquired HIV overseas. The proportion of heterosexually acquired HIV has also increased in WA (both locally and overseas-acquired) due to various socio-economic factors including the high number of people from high-prevalence countries entering the country on temporary visas (such as those entering on subclass 457 visas to support the resources boom).

GPs are urged to offer HIV testing to at-risk patients who travel frequently to high-prevalence countries, either for work or pleasure, and to patients from countries with a high HIV prevalence.

The Department of Health recognises the need to raise awareness about the increased risk of exposure to HIV in high-prevalence countries. The Department currently funds the WA AIDS Council to promote safe sex messages to people travelling to high-risk countries. For more information visit the WA AIDS Council’s Sex in Other Cities (external site)

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Increasing gonorrhoea notifications among non-Aboriginal Western Australians

Western Australia has consistently reported the second highest notification rate for gonorrhoea of all jurisdictions, after the Northern Territory. Historically, high rates in WA have reflected the large number and proportion of cases (~80%) reported among Aboriginal people, mostly from rural and remote regions, in the past resulting in rates over 100 times higher than in non-Aboriginal people.

In 2012, a record high of 2,102 gonococcal infections were notified among Western Australians. From 2009 (when the increase commenced) to 2012, the WA gonococcal notification rate increased by 47%, and a doubling in rates was observed in the non-Aboriginal population and in the Perth metropolitan region. Because the recent rise in gonorrhoea in WA can be attributed mostly to increases among non-Aboriginal people, this article highlights changes in the epidemiology of gonorrhoea in this group.

Figure 1 shows gonorrhoea notification numbers and rates among Aboriginal and non-Aboriginal Western Australians for the period 2007 to 2012. Among Aboriginal people, there was an overall decline in the number and rate of notifications, by 14% and 20% respectively. Among non-Aboriginal people, however, the number and rate of notifications increased by 230% and 200% respectively, albeit from a much lower base. Despite an apparent convergance of rates, the Aboriginal rate was 36 times higher than the non-Aboriginal rate in 2012 (1,485 versus 41 per 100,000 population).

Notification rates (per 100,000 population) for gonorrhoea in Aboriginal and non-Aboriginal Western Australians, 2007 to 2012 (note the different scales)

Number of gonorrhoea notifications in Aboriginal and non-Aboriginal Western Australians, 2007 to 2012

Figure 1 – Line graph: Notification rates (per 100,000 population) for gonorrhoea in Aboriginal and non-Aboriginal Western Australians, 2007 to 2012 (note the different scales)
Bar graph: Number of gonorrhoea notifications in Aboriginal and non-Aboriginal Western Australians, 2007 to 2012

Sex

From 2007–2012, gonorrhoea notification rates among non-Aboriginal males were, on average, three times that of their female counterparts. There were marked increases in notification rates over this period for both sexes, with the increase occurring one year earlier in males (2010 vs 2011). However, between 2009 and 2012, the gonorrhoea notification rate increased more in females (2.7 times) than in males (2 times).

Figure 2 – Notification rates (per 100,000 population) for gonorrhoea in non-Aboriginal Western Australians by sex, 2007 to 2012

Figure 2 – Notification rates (per 100,000 population) for gonorrhoea in non-Aboriginal Western Australians by sex, 2007 to 2012

Region

In 2012, the majority (84%) of non-Aboriginal people notified with gonorrhoea resided in the Perth metropolitan region. From 2009 to 2012, notification rates in non-Aboriginal people doubled in both metropolitan and non-metropolitan regions. While notification rates in males increased 2-fold in both the metropolitan and non-metropolitan regions, rates in females increased 2.8 and 2.5 times, respectively.

Age

Among non-Aboriginal people, older teenagers and young adults (aged 15–24 years) continued to have the highest gonorrhoea notification rates; and these doubled between 2011 and 2012. In 2012, 40% of notifications were in this age group (up from 29% in 2011) , followed by adults aged 25–34 years (34% of notifications) in whom rates had increased steadily since 2009 (Figure 3). Increases in those aged 35 years and above were less dramatic.

Figure 3 – Age-specific notification rates (per 100,000 population) for gonorrhoea in non-Aboriginal Western Australians, 2007 to 2012

Figure 3 – Age-specific notification rates (per 100,000 population) for gonorrhoea in non-Aboriginal Western Australians, 2007 to 2012

Sex of partner

Information on "sex of partner" was available for 90% of non-Aboriginal gonorrhoea cases reported in 2012, with the presumed source of infection attributed to heterosexual males (42% of cases), heterosexual females (31%) and men who have sex with men (MSM) (26%). Numbers increased in all three categories over time, most evident in the Perth metropolitan area, with little change in country areas (Figure 4).

Figure 4 – Number of gonorrhoea notifications in non-Aboriginal Western Australians, 2007 to 2012, by region of residence and sex of partner

Figure 4 – Number of gonorrhoea notifications in non-Aboriginal Western Australians, 2007 to 2012, by region of residence and sex of partner

Place of acquisition

In 2012, the majority of gonococcal infections among non-Aboriginal Western Australians were acquired in WA (75%), followed by overseas (19%) and interstate (4%). From 2009 to 2012, there was a greater increase in the number of locally acquired infections (269% increase) compared to overseas-acquired infections (62%) (Figure 5). Of the 178 cases acquired overseas in 2012, the vast majority were male (87%) and the most commonly reported countries of acquisition were Thailand and Indonesia (30% each), followed by the Philippines (11%).

In 2012, the majority of gonococcal infections among non-Aboriginal Western Australians were acquired in WA (75%), followed by overseas (19%) and interstate (4%). From 2009 to 2012, there was a greater increase in the number of locally acquired infections (269% increase) compared to overseas-acquired infections (62%) (Figure 5). Of the 178 cases acquired overseas in 2012, the vast majority were male (87%) and the most commonly reported countries of acquisition were Thailand and Indonesia (30% each), followed by the Philippines (11%).

Figure 5 – Number of gonorrhoea notifications in non-Aboriginal Western Australians, 2007 to 2012, by sex and place of acquisition

Figure 5 – Number of gonorrhoea notifications in non-Aboriginal Western Australians, 2007 to 2012, by sex and place of acquisition

Conclusion

The recent sharp increase in gonorrhoea infections among non-Aboriginal Western Australians, particularly in younger heterosexual adults and including females, is of concern. The increase indicates a possible decline in safe sex practices and the establishment of gonorrhoea transmission among young non-Aboriginal people. Gonorrhoea is a significant public health concern, not only because of its long-term impact on fertility, but also because of decreasing sensitivity to the current suite of antimicrobial drugs (including the cephalosporins in some countries) and the increased risk of HIV transmission associated with the presence of another sexually transmitted infection.

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Increasing impact of Bali travel on infectious disease notifications in Western Australia

Background

From 2006 to 2012, the number of people flying from Western Australia (WA) to Bali increased more than 6-fold, while the proportion of WA trips destined for Bali rose from 7% to 24%. In 2012 there were more than 400 000 people on flights to Bali from WA, from a resident population of 2.4 million.

Impact on disease notifications

For most diseases, the Western Australian Notifiable Infectious Disease Database records travel details only to the country (e.g. Indonesia), not to the regional level. However, nearly all Indonesian-acquired infections are likely to be from Bali, given that 93% of travellers to Indonesia in the period from 2006 to 2012 flew to Bali.

In line with increased numbers of Western Australians flying to Bali, the number of Indonesian-acquired notifiable disease cases also increased 6-fold from 2006 to 2012 (173 to 1069 cases, respectively), and the proportion of overseas-acquired cases attributed to infection in Indonesia increased from 10% to 29% of cases (Figure 1).

Figure 1 – Number of notifiable disease cases reported in Western Australia that were acquired in Indonesia and other countries, and Bali travel population from WA, 2006 to 2012
Figure 1 – Number of notifiable disease cases reported in Western Australia that were acquired
in Indonesia and other countries, and Bali travel population from WA, 2006 to 2012

From 2006 to 2012 the notifiable diseases on which Bali travel had the greatest impact were dengue fever and Salmonella infection.

From 2006 to 2012, there was a 46-fold increase in the number of Indonesian-acquired cases of dengue fever (9 and 415 cases, respectively) and the proportion of all dengue fever cases notified in WA that were acquired in Indonesia increased from 56% to 80%. In 2012, 40% of all notified Indonesian-acquired infections were dengue fever (Figure 2).

Figure 2 – Indonesian-acquired notifiable infectious diseases in Western Australians by disease, 2012
Figure 2 – Indonesian-acquired notifiable infectious diseases in Western Australians by disease, 2012

The number of notified Salmonella infections acquired in Indonesia increased 9-fold (from 28 to 266) from 2006 to 2012, and the proportion of all Salmonella cases notified in WA that were acquired in Indonesia rose from 4% to 23%. In 2012, 25% of Indonesian-acquired notifiable diseases were Salmonella infections. For both dengue fever and Salmonella, the increase in case numbers from 2006 to 2012 was greater than expected based on the 6-fold increase in Bali travel population. This suggests that during this period the risk of transmission in Bali also increased for both diseases. This could reflect changes in local factors in Bali, such as a decline in food safety standards and increased dengue virus transmission, and/or greater risk-taking by WA travellers.

Other diseases which comprised more than 5% of Indonesian-acquired cases in 2012 were Campylobacter and Chlamydia infections (157 and 95 cases respectively), but for these diseases the increase in notifications from 2006 to 2012 (4.2 and 3.8 fold, respectively) was less than expected based on the increased Bali travel population. In addition to dengue fever, salmonellosis, campylobacterisosis and chlamydia, in 2012 there were 10 or more Indonesian-acquired notifications for each of gonorrhoea (n=37), Cryptosporidium infection (n=14), and Rickettsial infections (n=10), primarily murine typhus. Other less commonly acquired notifiable infectious diseases included syphilis, typhoid fever, hepatitis A,chikungunya and Legionnaires’ disease.

An additional and very significant impact of increased Bali travel has been the provision of rabies post-exposure prophylaxis to people reporting bites or scratches from local animals, mostly monkeys, but including dogs. Since 2008, 536 people have been provided with prophylaxis, 157 of these in 2012. This normally requires an expensive course comprising administration of both human rabies immunoglobulin and several doses of rabies vaccine, even if the course has been commenced in Bali prior to departure.

Conclusions and recommendations

The main notifiable infectious disease risks for travellers to Bali are from mosquito-borne, gastrointestinal and sexually transmitted infections. WA travellers need to be more aware of these risks and take appropriate precautions to prevent infection. In addition to travel vaccination recommendations, pre-travel advice should include information on preventing mosquito bites, diarrhoeal diseases and sexually transmitted infections.

Mosquito bites can be prevented by:

  • applying insect repellents containing diethyl toluamide (DEET) or picaridin
  • wearing long, loose-fitting, light-coloured protective clothing
  • sleeping in screened accommodation or using bed nets.

People travelling to Bali and other dengue-affected areas should be aware that the mosquito that transmits dengue fever commonly bites during the day and in shady, indoor situations.

Diarrhoeal diseases, can be prevented by:

  • not consuming foods or drinks purchased from street vendors or other places where conditions may be unhygienic
  • not eating raw or undercooked meat and seafood
  • not eating undercooked eggs
  • not eating raw fruits (e.g., oranges, bananas, avocados) and vegetables unless the traveller peels them
  • not drinking tap water, ice or unpasteurised milk. Safe beverages include bottled carbonated beverages, hot tea or coffee, beer, wine, and water boiled or appropriately treated with iodine or chlorine.

Sexually transmitted infections can be prevented by practising safe sex and always using a condom and lubricant with any casual sexual partners.

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